Neuropati Perifer

Iwan setiawan
Bagian Penyakit Saraf
FK UMS

Neuropati

Merupakan suatu penyakit atau

cedera yang mengenai susunan saraf
tepi baik sensorik, motorik maupun
otonom.
Neuropati dapat hanya mengenai
serabut motorik saja, sensorik saja
ataupun campuran keduanya

Klasifikasi berdasarkan patologi

Neuronal degeneration (akibat

kerusakan pada sel bodi saraf
sensorik maupun motorik)
Wallerian degeneration
Axonal degeneration (kerusakan axon
yang difus)
Segmental degeneration (kerusakan
selubung mielin tanpa disertai
kerusakan axon)

Faktor risiko Neuropati perifer

Nutritional deficiencies, such as B-12 and folate

deficiency
Medications known to cause peripheral
neuropathy, include several AIDS drugs (DDC and
DDI), antibiotics (metronidazole, an antibiotic used
for Crohn's disease, isoniazid used for TB), gold
compounds (used for rheumatoid arthritis), some
chemotherapy drugs (such as vincristine and
others) and many others.
Chemicals known to cause peripheral
neuropathy : alcohol, lead, arsenic, mercury and
organophosphate pesticides.

Gangguan pada Saraf:

berdasarkan Lokasi

Radix
Plexus
Single nerve
Several nerves
mononeuropathy,

radiculopathy
plexopathy
mononeuropathy
multiple
mononeuritis

multiplex
All nerves,
polyneuropathy
length-dependent
All nerves,
polyradiculoneuropathy
not length-dependent

Radix

Segmental loss of
motor
atrophy
weakness
reflexes
sensation

Signs usually minimal; symptoms

can be severe (pain);
Usually only one limb.

Plexus

Pain
Weakness, atrophy, variable, but
usually more severe than
radiculopathy
Usually restricted to one limb
Etiology:
Brachial: trauma, neoplasm, idiopathic
Lumbosacral: diabetes, neoplasm

Single nerve (mononeuropathy)

Restricted distribution
Pain, numbness or tingling,
atrophy, weakness
Etiology:
entrapment
trauma

Several nerves (mononeuritis

multiplex)

Often painful at onset

Often sudden
Deficits in the distribution of
several peripheral nerves (one at a
time)
Etiology: vasculitis

All nerves: Length-dependent

(polyneuropathy)

Lower before upper extremity

Distal first (feet)
Atrophy of intrinsic foot muscles
Decreased ankle jerks
Stocking, then glove sensory loss
Distal motor and sensory findings
always much more severe than
proximal

Causes of polyneuropathy
Infectious disease

Leprosy
HIV , Lyme disease

Inflammatory

Acue Inflammatory demyelinating polyneuropathy

CIDP, Multifocal motor neuropathy
Collagen vascular disease, vasculitis

Other systemic
disease

Diabetes mellitus, Chronic renal failure,

Thyroid dysfunction, Parathyroid dysfunction,
Paraproteinemia, amyloidosis, Vitamin deficiency,
critical illness neuropathy

Genetic disorde

Hereditary motor sensory neuropathies,

Hereditary sensory and autonomic neuropathies

Toxins

Therapeutic drugs (chemotherapeutic agents,

antiviral, statins), Drugs abuse (alcohol, aromatic
hydrocarbons), poisons (arsenic, n-hexane)

Abnormal
Vasa
Nervorum
Abnormal
Fatty acid
metabolism

Insulin Deficiency
Hyperglycemi
a
Polyol activity
NOS
Activity

Nerve
Ischemic

Uptake
Myo-inositol
Nerve
Myoinositol

Nerve
Function
Abnormal
Morphometr
y

Glycosylation
Neural Proteins
Axonal
Transport

Confirmed
Clinical
Neuropathy

Foot Ulcer
Amputatio
n

Development of
Neural Autoantibodies

Ulnar neuropathy

Numbness
Atrophy of first
dorsal interosseous
Weakness
Compression at
elbow
Entrapment in
cubital tunnel
Distal injury

Radial nerve: Saturday night palsy

Weakness of wrist
& finger extensors,
brachioradialis
Pressure palsy
Trauma (humerus
fracture)

Peroneal palsy

Crossing legs
Weight loss
Hospitalizatio
n
Surgery

Polyneuropathy (contd)

Polyneuropathy (contd)

Most common kind of neuropathy

Etiology
metabolic (diabetes, renal failure)
nutritional (thiamine, B12 deficiency)
toxic (heavy metals, organic solvents,

some drugs)
familial (Charcot-Marie-Tooth)

Guillain-Barre syndrome

Progresses over days to <4 weeks

Typically ascending weakness
Reflexes lost early
Motor symptoms predominate, but
can affect sensation and autonomic
function
Respiratory failure requires support

Guillain-Barre syndrome (contd)

Etiology: autoimmune
target antigen usually unknown
In some cases: specific gangliosides (GM1,

GQ1d... May correlate with symptoms

Precipitating factors: infection

(campylobacter, CMV), immunization,
surgery, trauma...
Treatment: IVIG, plasma exchange,
support

Neuropati otonom

Keringat berkurang
Hipotensi ortostatik
Nokturnal diare
Inkontinensia alvi, konstipasi
Inkontinensia & retensio urine
Gastroparesis
impotensi

Table . Clinical Manifestations of Autonomic Neuropathy

Cardiovascular

: Tachycardia, exercise intolerance

- Heat intolerance
Cardiac denervation, painless myocardial infarction
Orthostatic hypotension
- Alterations in skin blood flow

Gastrointestinal : Esophageal dysfunction

- Gastroparesis diabeticorum
Diarrhea
- Constipation
Fecal incontinence
Genitourinary: Erectile dysfunction
Cystopathy

- Retrograde ejaculation
- Neurogenic bladder

Sweating disturbances: Areas of symmetrical anhydrosis

Gustatory sweating
Metabolic

: Hypoglycemia unawareness
Hypoglycemia unresponsiveness

Pupillary

: Decreased diameter of dark adapted pupil

Argyll-Robertson type pupil

Nyeri Muskuloskeletal

Sistem muskuloskeletal meliputi otot,

tendon, sendi, dan bursa.
Nyeri muskuloskeletal merupakan
nyeri yang berasal dari otot, tendon,
sendi dan bursa.

Fibromyalgia

Sindroma Fibromialgia adalah nyeri

kronik yang penyebabnya belum
diketahui.
Ditandai oleh nyeri muskuloskeletal
yang tersebar luas, kekakuan dan
kelelahan menyeluruh.

Fibromyalgia
Penyebab tidak diketahui,
diperkirakan ada 6 pencetus potensial
yaitu:
Gangguan tidur / kurang tidur
Abnormalitas neurobiochemical
Hilangnya kontrol sistem saraf
simpatis
Faktor jaringan setempat
Trauma fisik atau infeksi virus
Faktor Psikologis

Fibromyalgia

Lima Gejala Klinis

(1) nyeri,
(2) kaku,
(3) edema jaringan lunak,
(4) titik nyeri dan
(5) spasme otot dan nodul. Gejala
yang khas adalah nyeri yang difus,
menyebar atau nyeri yang
berfluktuasi yang sering disertai
kekakuan yang menonjol.

Fibromyalgia

Widespread pain adalah nyeri yang

meliputi nyeri aksial, nyeri pada sisi
kiri dan kanan tubuh, serta nyeri
pada segmen atas dan bawah tubuh
Chronic widespread pain yang
berlangsung sekurang-kurangnya
selama 3 bulan merupakan klinis
utama pada fibromialgia

Fibromyalgia
Penatalaksanaan :
Tidak ada obat yang spesifik
Edukasi
Farmakoterapi : Asetaminofen, NSAIDs, Tramadol, muscle
relaxant, antidepresan trisiklik (amitriptilin 10-25 mg,
nortriptilin), antidepresan SSRI (fluoxetine, sertralin)
Injeksi topikal lidokain dikombinasikan dengan kortikosteroid
di titik nyeri (tender points)
Akupuncture
Cognitive Behaviour Therapy
Latihan fisik : postural exercise, passive stretching,
bersepeda, berenang, jalan-jalan. Latihan dilakukan tiga kali
dalam seminggu.
Disarankan mandi dengan air hangat
Nutrisi : hindari kafein, alkohol dan nikotin